Introduction to the management of safety New ICAO Annex 19 Jean-Pierre ARNAUD R4.2 Rulemaking officer 27 June 2012

Introduction to safety management - 27 june 2012 ICAO definition of SMS Safety Management System (SMS): a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures It provides a systematic way to identify hazards and control risks while maintaining assurance that these risk controls are effective. Did you understand? ..me neither! A safety management system is woven into the fabric of an organization. It becomes part of the culture, the way people do their jobs. An effective SMS should: • Define how the organization is set up to manage risk. • Identify workplace risk and implement suitable controls. • Implement effective communications across all levels of the organization. • Implement a process to identify and correct non-conformities. • Implement a continual improvement process. Applicability to all States and organisations providing: Training services Operations of aircraft Maintenance of aircraft design and manufacturing of aircraft Air navigation services Aerodromes Accident and incident investigation boards Let’s try another way… Introduction to safety management - 27 june 2012

Safety policy and Objectives Safety risk management On the menu today… Safety policy and Objectives Safety risk management Safety Assurance Safety Promotion ICAO Annex 19 + challenges The four components are applicable to: The service provider The State (just add “State” in front of the title) For sure every component has specifics Introduction to safety management - 27 june 2012

Component n’2: Safety risk management Safety policy and Objectives Safety risk management Safety Assurance Safety Promotion Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 The Titanic case Centennial of the ship’s sinking Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 14 April 1912 The largest steamer in the world…promoted as the “unsinkable”…sunk! The court reported that the loss of the Titanic was due to collision with an iceberg, brought about by the excessive speed at which the ship was being navigated. Weather and navigation conditions Calm night, flat surface – no noise, no light reflect of waves No moonlight at all: no visibility In April icebergs remain a hazard when you navigate north and the probability to hit an iceberg is high. 1912 was reported to be a very cold year with numerous iceberg straying abnormally southerly. ………………...role of observation, statistics and metrics... More than 700 out of 2200 souls perished Introduction to safety management - 27 june 2012

Additional noticeable safety factors Applicability Design: double bottom; built to remain afloat if as many of 4 of its watertight compartments were flooded; after the collision, 5 flooded Manufacturing: One allegation is that, under great pressure, the shipyard resorted to using second-rate iron rivets Operational rules: Titanic did not carry enough lifeboats to save all aboard although it met British safety codes – out-dated, however the most advanced at that time Certification and Operations + organizational factors: Inadequate emergency procedures: Lifeboat n’1 departed with only 12 people instead of 40. Several lifeboats were unusable due to the configuration of the sinking It was a maiden voyage No real test of the ship in operations and no training in real conditions Not enough experience (evacuation, size of the boat, configuration etc) Navigation services Titanic received 6 messages on April 14 warning of the approaching ice field – all disregarded Several noticeable safety factors: To earn its reputation as “unsinkable”, the ship had a double bottom and 16 watertight compartments in its hull. Titanic was built to remain afloat if as many of 4 of its watertight compartments were flooded Its reputation was based on belief and complacency ( the biggest ever man-made ship complying with the best rules -“God himself could not sink this ship”) 5 compartments were inundated Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Piling pressures… The alleged root reasons why the captain persevered in his course, and maintained high speed, is probably to be found: in competition with other transportation means The captain of the ship was allegedly invited to set a speed record for its landmark maiden journey between Southampton and NY in order to increase the profit of the investors; Therefore the ship navigated too northerly in order to save time. in the desire of the public for quick passages rather than in the judgement of navigators (safety culture) in the beliefs he had in the boat (« unsinkable » ) Human factor - overconfidence Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Titanic case Hazard Collision with iceberg Probability and severity High if you navigate northerly Higher with no moonlight Very high if you ignore the warning messages Risk is the combination of hazard and probability of severity Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Titanic case How to mitigate the risk? Reduce speed Increase vigilance Re-enforce radio monitoring Navigate more southerly of Canada Take timely effective management decision This is called risk management: Identify hazard, evaluate the risk, assess whether it is acceptable, mitigate the risk if necessary, to reduce the risk to an acceptable level The Titanic case is clearly a failure in risk management as all information were available to avoid the accident. Risk management is a subset of safety management (component n’2) Introduction to safety management - 27 june 2012

This accident also highlights… Just culture – (non) Criminalization The captain was cleared of blame Safety culture Captain (retired for the night at 21h30 dispite the warning messages about icebergs) Crew team (no one questioned the captain’s decision) Senior management of the operator and manufacturer pushing for accelerating the assembling of the steamer Shareholders (money, money, money…) The need to have an effective decision-making management process in operations CONCORDE JET CRASH: the mechanics were charged with negligence Introduction to safety management - 27 june 2012

What can we learn from this event? This event is not out of date and the root causes are still of interests in the aviation domain: Human factor, piling pressure from shareholders, safety culture, organizational and human factors… Safety management applies to any domains: Nuclear, railways etc…even your private life… Rules, design, certification, manufacturing, operations, navigation services, infrastructure… Safety management is not a novelty: Clinical approach started in the 90’s ICAO started to adopt SARPs in 2003 Accident investigation boards have been repeatedly highly recommended to implement it asap. Was is just negligence? You do it naturally everyday – let’s take an example Let’s imagine you have to drive 12h tomorrow, 1000 kms: The day before you are not going to drink You will pack the day before so that you can go early to bed (fatigue management) Maintenance of the car: be sure the tire are correctly inflated, check the oil, refill the tank, repair the brakes You will plan a break every two hour. For the kids, you install video or plan games so that they remain calm, busy In that sense: you have identify the hazards; fatigue, breakdown of the car, your mental and physica condition Naturally you have decided to sleep, not to drink alcohol etc (mitigating factors0 And you have reduced the level of risk Introduction to safety management - 27 june 2012

Safety risk management Safety policy and Objectives That was Safety risk management Safety Assurance Safety Promotion Introduction to safety management - 27 june 2012

Safety risk management Key Words: Hazard, consequence, risk, mitigating factors, risk management. Challenges: Identify the relevant hazards Reporting systems and all kinds of safety information will help; Assess correctly the probability and severity Collection of data and sharing will help; Address the appropriate mitigating factors; Effectively manage the safety of the operations; Exchange of information on safety data, safety hazards and risks between stakeholders. Definitions Hazard – (natural – weather, volcanic eruption, technical - deficiencies, tools economics – growth, recession, costs) Condition or object with the potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function Consequence – Potential outcome(s) of the hazard Safety Risk – The assessment, expressed in terms of predicted probability and severity, of the consequence(s) of a hazard taking as reference the worst foreseeable situation Probability : The likelihood that an unsafe event or condition might occur Severity The possible effects of an unsafe event or condition, taking as reference the worst foreseeable situation Introduction to safety management - 27 june 2012

Component n’3 is Safety Assurance Safety policy and Objectives Now Safety Assurance Safety Promotion Safety risk management Introduction to safety management - 27 june 2012

Paramount objective of the safety management To reduce the accident rate per million flights Currently around 4 accident per million flights (next slide – source ICAO MTOW above 2250kg) Introduction to safety management - 27 june 2012

Which year would you prefer to travel? First level Second level Third level Fourth level Fifth level …If you had this kind of indicators in your life…. …you would start to manage your life differently… Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Safety intelligence With the advent of the computer, data serve as a comprehensive source of aviation safety information. Technology explores all domains and brings us a huge amount of data for analysis Equipment monitor and record everything, even satellites… Statistics is everywhere Mandatory and voluntary incident and accident reporting system, helping in identifying hazards. Predicting …the future… (proactive approach) by selecting the right metrics…. and then acting consequently… Examples of information available thanks to technology Digital aircraft (on board computers aircraft, DFDR, CVR, GPWS), satellite surveillance, equipments (aerodrome, ATS, MTO, maintenance reliability etc), health data Statistics are available everywhere: Accidents, incidents, reporting systems Audits – oversight – LEIs (lack of effective implementation) Economic indicators Traffic volume – traffic growth – congested areas Flight data (ex: stability of approaches) Flight path (tracking system – spacing -deviation) Reliability of maintenance components etc Introduction to safety management - 27 june 2012

Active failure versus latent failure The accidents are just tips of the iceberg named “active failures”. There is still a vast quantity of data from the bottom of the iceberg, called “latent failures” waiting for triggering factors in order to emerge. Examples for operations: Flight data monitoring programme Tracking the flight path LOSA (monitoring the operations in the decks) Others instances (main contributors in accident): Runway safety related (incursions, excursion, ground collisions) - Ex: reported accidents and serious incidents involving runway excursions has increased during the last decade Loss of control in-flight Controlled flight into terrain When you ask a CEO, “what is your priority?” He/she will answer “Safety”. Then ask him/her: “how much do you budget for your safety office or your safety culture? Generally the answer is blurred. Safety-related data intelligence and safety analysis highlights capabilities that assist organisations in: Identifying hazard and risks (systematically or using reporting systems, incidents, any safety-related events or reports, audits, safety studies, experience etc); Collecting and analyzing all these data available; Getting the trends and acting consequently… Introduction to safety management - 27 june 2012 19

Introduction to safety management - 27 june 2012 Proactive approach Each State or each service provider has to: Collect safety-related data and analyse them; Set up key safety indicators reflecting its activities; Define and target objectives; Monitor the system in place by evaluating the overall performance of the system; Improve or maintain its safety performance; Eventually allocate the most-effective resources to meet these objectives. This is called the “proactive approach”. In addition, the State will oversee the Safety Performance Indicators (SPIs) of the services providers and share data. You will often hear: Acceptable level of safety (ALoS) Acceptable level of safety performance (ALoSP) Parallel with your work: Every day you arrive on time, you leave on time, no more than one hour lunch break (you comply with the rules) You do your job You reply Emails But have you already assess: The hazard surrounding your activities What is the risk that the system fails How do you perform overall? Do you have objectives or measurement tools? What is the risk that an unexpected event disrupt your performance or the performance of the service? What would be the consequences? Do you receive too many Emails or too little? Is there a way to measure it? Would you be blamed if you report an error? Are you sure you interface correctly within the organization? Predictive - Any method that continuously analyzes current and historical information to forecast potential future occurrences. Proactive - Any method that actively searches for potential safety risks through the analysis of an organization's activities prior to occurrence Reactive - Any method that responds to past occurrences Introduction to safety management - 27 june 2012

High-level instances (main contributors in accident) Runway safety related (incursions, excursion, ground collisions) EX: reported accidents and serious incidents involving runway excursions has increased during the last decade Loss of control in-flight Controlled flight into terrain Collision in flight Unfortunately the accidents / serious incidents since the beginning of 2012 already confirm these main contributors; just take the last 30 days before this presentation was built: 20 June: - Japan – B767 –Severe windshield and gusty winds reported before the hard landing – no fatalities 10 June – Ukraine – Russian-made aircraft crashed into the field – 5 fatalities – heavy rainstorm 9 June –Peru - Helicopter crashed in the mountains, exploring sites for a possible hydroelectric plant – 14 fatalities 03 June – Nigeria – MD83 – crashed into a residential area of Lagos – 163 fatalities – The crew reported an emergency 11Nm from the field 02 June – Ghana – B727 cargo – Runway excursion – thunderstorm reported – 13 fatalities 28 May – USA – mid-air collision - 02 fatalities These are also the main objectives of GASP and EASP. Another instance for maintenance: A recent study shows that middle management encourages to deviate to the SOPs (refer to www.bainessimmons.com/ - “Driving your SMS beyond compliance towards performance”) 28/03/2017 change via "view" > "header and footer"

Instances of low-level safety metrics State Development/absence of primary aviation legislation or operating regulations Level of regulatory compliance – Lack of Effective Implementation (LEI – USOAP ICAO indicator) Does the audit programme cover all activities? State and organisation Incident rate or incidents reported Number of deviations to the SOPs (Standard Operating Procedures) Organisation Measurement of safety culture in an organisation or open climate in an organisation for reporting MTBF for maintenance (Aircraft, ANS and Aerodrome) Dispatch or stabilized approaches (operations)… Deviations to the flight path or separation (Air Navigation Services) Bird strikes (Aerodrome) Introduction to safety management - 27 june 2012

The data will set you free…. It should never be forgotten what the ultimate point of the ECR actually is, to provide the best possible understanding of safety events so that lives can be saved by using the information find out what the safety problems are and how to fix them. “The goal is to transform data into information, and information into insight” Ernest Greenwood Introduction to safety management - 27 june 2012

Component n’3 is Safety Assurance Safety policy and Objectives That was Safety Assurance Safety Promotion Safety risk management Introduction to safety management - 27 june 2012

Challenges and key words for safety assurance Safety assurance based on effective safety data-driven processes but not being entirely data-driven; Collecting information in an organized and standardized manner; sharing and protecting information; Setting the right Key Safety Indicators (moving from concept towards implementable / practical KSIs); Managing properly (safety trends and effective decision making); Collaboration between States and Service Providers (KSIs) Compliance with the rules remains a must Develop performance-based oversight and performance – based rules Enhancement of regional agencies (RSOOs – oversight and RAIOs –Accident, incidents), eliminating duplication of efforts, fostering cooperation (sharing information - databases) and independency RSOOs: Regional Safety Oversight Organisation RAIO: Regional Aviation Investigation Organisation, Introduction to safety management - 27 june 2012

Component n’4 is Safety Promotion Safety policy and Objectives Now Safety Promotion Safety risk management Safety assurance Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Safety promotion Safety promotion based on Internal and external training Communication and dissemination of safety information Train (initial and continuous) your staff, educate, inform, increase the level of safety awareness, promote your policy and your objective, communicate, instruct, share… Develop and maintain the level of “safety culture” among the States, the organisations or any stakeholders playing a role in safety It includes senior management, front-line management, staff in the field, decision-makers etc Introduction to safety management - 27 june 2012

Introduction to safety management - 27 June 2012 What is Safety culture? Safety culture is the set of enduring values and attitudes regarding safety issues, shared by every member at every level of an organization. Refers to the extent to which every individual of the organization is aware of the risks and unknown (?) hazards induced by their activities Objective: Raising and maintaining the level of awareness In that sense, component n°4 of the safety management is the safety awareness promotion Is an integral part of Safety Management A strong Safety Culture is generally considered as a vital condition to a well functioning SMS. It is sometimes said that is it is well possible to have a good Safety Culture without a formal SMS, but is not possible to have an effective SMS without a good Safety Culture. The individual is: continuously behaving so as to preserve and enhance safety; willing and able to adapt itself when facing safety issues willing to communicate safety issues; and consistently evaluates safety related behaviour. Introduction to safety management - 27 June 2012 28

Concorde and safety culture (1) Concorde F-BTSC accident, 25 July 2000, France 109 casualties, a/c destroyed Source: final investigation report, available at http://www.bea.aero/docspa/2000/f-sc000725a/htm/f-sc000725a.html The French BEA concluded in 2002 that a wear strip of metal, fallen off from a DC-10 that took off 4 minutes earlier, had punctured a tire of the Concorde, sending shards of rubber into the fuel tanks, leading to flames pouring from its undercarriage and making the plane crashing into a hotel few kilometers away. The strip was attached with rivets close to other previous existing holes (reverse of the engine) and was improperly attached Introduction to safety management - 27 june 2012 29 29

Introduction to safety management - 27 june 2012 Concorde and safety culture (2) Who could have thought that this 40cm long piece of metal was a killer? Not even the mechanic who did the repair… The loss of the wear strip from the thrust reverser door of the DC-10 originated from lack of rigorous maintenance. 8 holes and rivets over 5 cm long Introduction to safety management - 27 june 2012 30 30

Introduction to safety management - 27 june 2012 Concorde and safety culture (3) Introduction to safety management - 27 june 2012 31 31

Introduction to safety management - 27 june 2012 Concorde and safety culture (4) Introduction to safety management - 27 june 2012 32 32

DC10 reverse as found How it should be Holes too close 37 holes in total Correct spacing – 12 holes were only allowed Introduction to safety management - 27 june 2012 33

Concorde and safety culture (6) The engine cowl support was drilled with 37 holes whereas the installation of the strip required only 12. Therefore the strip was attached with rivets close to other previous existing holes and was improperly attached, resulting in it falling onto the runway. The mechanic (a metal sheet worker, not a certifying staff) used titanium, rather than aluminium (higher resistance), to construct a replacement piece (deviation to the maintenance repair as prescribed by the engine manufacturer). The mechanic who did the repair and the certifying staff who released to service the aircraft were charged with negligence (just culture). This part had been replaced during a C check 6 weeks before the accident took place. 3 weeks after the C check, the part detached again and was replaced by another part (the one fell off on 25 July 2000). These signals should have alerted the maintenance organization that improper maintenance had been carried out and that the trouble shooting was poor. The organisation was charged with negligence. Introduction to safety management - 27 june 2012 34 34

Component n’4 is Safety Promotion Safety policy and Objectives That was Safety Promotion Safety risk management Safety assurance Introduction to safety management - 27 june 2012

Safety policy and Objectives Component n’1 is: Now Safety policy and Objectives Safety risk management Safety Promotion Safety Assurance Introduction to safety management - 27 june 2012

Component n’1: Policies and Objectives Responsibilities, accountabilities and commitment, including identification of key safety personnel A legislative framework for the State An accident and incident investigation for the State A mandatory and voluntary incident reporting system (State and service provider) Policies and resources to collect and analyse safety data An emergency response planning for the service provider A process to set-up objectives, policies, monitoring and maintaining…then train and communicate… Documentation (process, manual and procedures) The management of changes An enforcement policy Introduction to safety management - 27 june 2012

About the reporting system… Report! And avoid the sinking… It must Be voluntary; Be anonymous; Identify the hazards and better understand the latent failures Should not lead to any blaming except in the case of malicious act or gross negligence (this is called “just culture”) Be supported by a statement / commitment of the accountable manager (no blaming) Just culture (definition): an atmosphere of trust in which people are encouraged for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. Examples: Difference between one-off and routine non-compliances; Company Benefit versus Personal Benefit; Importance of non-punishment or punishment (reckless attitude or deliberate non-adherence to the procedures); Evaluation of safety related behaviors; Non-compliance as a natural human response to poor planning in the field or long-ingrained culture of non compliances; Bad intention (in general no one reports it!). Just culture entails understanding and situational awareness of safety hazards. Just culture reflects the extent to which: safe behavior and reporting of safety issues are encouraged or even rewarded (blame-free); and unsafe behavior is discouraged (discipline is appropriate or coaching/training is required). Introduction to safety management - 27 june 2012

Safety policies and objectives - component n’1 Key words: Just culture Challenges: Criminalization or lay off of staff Protection of persons and data Commitment of the personnel and effective implementation of the policies In particular middle and front-line management (leadership and safety culture in the field play essential roles) Safety vision Transparency and sharing Effective implementation Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Vocabulary The safety management is called: SSP (Sate Safety Programme) for the State EASA has developed the EASP ICAO has developed the GASP SMS (Safety Management System) for the service provider. EASP: European Aviation Safety Programme (see EASA website) It contains 91 actions (covering operations , promotion of safety or safety assurance) on which Safety Performance Indicators (SPIs) are established; For CAT:, the main contributors are: Runway excursions Mid-air collision Controlled flight into terrain Loss of control in flight + upset recovery training Ground collisions Also SPIs for helicopters and general aviation as well as actions about emerging issues such as climate change, volcanic ashes, automation (interfaces between the pilot and the machine), shortage of aviation staff in the future (NGAP) The programme enhances the coordination between all stakeholders: EC, states, Eurocontrol, SESAR (Single European Sky) It means that the hazards have been identified and a plan « who does what, when , how » is established; This document is updated on a yearly basis. GASP: Global Aviation Safety Programme – similar approach to EASP at the global level of ICAO Introduction to safety management - 27 june 2012

Main objectives of the State Safety Programme Ensure that a State has the minimum required regulatory framework in place Ensure coordination and harmonization amongst the State‘s regulatory and administrative organizations in their respective safety risk management roles Facilitate monitoring and measurement of the aggregate safety performance of the service providers Coordinate and continuously improve the State‘s safety management functions Provides appropriate oversight functions Promulgate and support effective implementation and interaction with service providers‘ SMS Facilitate data aggregation Facilitate information sharing Promote safety Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 What is ICAO Annex 19? Safety Management Introduction to safety management - 27 june 2012

What is Annex 19 First Edition Compilation of common existing safety management provisions from existing annexes into one single new annex: Annex 1 — Personnel Licensing   Annex 6 — Operation of Aircraft Part I — International Commercial Air Transport — Aeroplanes Part II — International General Aviation — Aeroplanes Part III — International Operations — Helicopters Annex 8 — Airworthiness of Aircraft Annex 11 — Air Traffic Services Annex 13 — Aircraft Accident and Incident Investigation Annex 14 — Aerodromes Volume I — Aerodrome Design and Operations Introduction to safety management - 27 june 2012

Applicability (Service providers) A) training services that are directly exposed to safety risks;   B) operation and maintenance of aeroplanes and helicopters involved in international commercial air transport; C) operation of aeroplanes and helicopters involved in international general aviation, except aerial work; D) type design and manufacture of aircraft, engines, and propellers; E) air navigation services; and F) operation of aerodromes. Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Content of Annex 19 Five chapters, 2 appendices and 2 attachments: Definitions Applicability State safety management responsibilities Appendix 1: State safety oversight system Attachment A: Framework for a State Safety Programme (SSP) Safety Management System (Service providers) Appendix 2: Framework for a safety management system (SMS) Safety data collection, analysis and exchange Attachment B: Legal guidance for the protection of information from safety data collection and processing systems Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Status of Annex 19 29 June 2012 Consultation phase – 3 months Nov 2012 Air Navigation Commission adopts it 14 Nov 2013 Applicable Note that, independently of the applicability date of Annex 19, most of the SARPS contained in Annex 19 are already applicable as they are existing SARPS transferred from other Annexes. Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 Benefit of Annex 19 The consolidation of provisions from six different Annexes into a new draft Annex had been undertaken with the intent of improving implementation: Enhancing the role of the State at a higher level (coordination between all domains and all stakeholders); Having a “legal” basis in one unique document; Developing harmonized standards that are applicable to several domains; Better identifying and developing the future needs; Having a dedicated ICAO panel, working on the next iterations (EC and EASA are members); Having a global vision through implementation. Introduction to safety management - 27 june 2012

Future needs or challenges Better integration between the SSP and the oversight system Better and higher State policy –not only at CAA level (implementation, overall performance and coordination between all actors) Collection, sharing and protection of data: Analysis and common formatting of safety data (standardisation) Identification of hazard Just culture (Criminalization) Better coordination between AIG and State, between States and Agencies Development of an Emergency Response Plan by both the State and the service provider Development of implementation guidance: Effective and efficient safety indicators Scalability Training – safety culture Industry and State (ex: oversight inspectors) Communication between State and Service Providers Moving from compliance towards performance Introduction to safety management - 27 june 2012

Benefit of integrated safety management What’s being put forward is a vision of a community identifying hazard sharing data etc The recent agreement signed off between EASA and Singapore illustrates this willingness. The role of Regional Agency and Regional investigation board is another example of cooperation and development. EASA / EASP: common objectives – 27 States Introduction to safety management - 27 june 2012

This is not an all-cure system It is not a revolution but an evolution Just a clinical approach of better managing safety a kind of “modern” management of safety with the available technological tools It is an additional layer Traditional compliance to the rules remains a must Safety management builds on this fundamental because most of the incidents or accident are due to deviation to the SOPs Make our processes and procedures more robust Raise our awareness – performance and safety culture Develop an integrated safety system (complex environment – needed coordination). Super human factor programme Introduction to safety management - 27 june 2012

Introduction to safety management - 27 june 2012 How does it affect EASA? Establishment of an EASP (the global safety vision): Identification of hazards and risks, safety performance indicators etc Coordination between all partners Being more data-driven, collecting all safety info (E2, E6) Review of our processes and procedures, introducing the management of risks on top of “compliance to the rules”: Certification of aircraft (C) Performance based oversight (Standardisation Inspection Annual Programme - SIAP) (S) – workshop next October Performance –based rules (R) Safety assurance (E) International cooperation and sharing (based on agreements) (E, R, C, S) Training and competence (EASA staff, States, stakeholders) Promotion of safety everywhere – safety culture Better managing our internal resources All domains of the Agency is impacted Introduction to safety management - 27 june 2012

Basic Safety Management Tool Kit ICAO Annex 19 Click here to access to the document SMM edition 3 (ICAO doc 9859) Rulemaking focal point within the Agency: Regine.hamelijnck@easa.europa.eu A more detailed presentation on Annex 19 is here available (click here) Introduction to safety management - 27 june 2012

Advanced safety management tool kit Noteworthy websites about Safety management in aviation http://flightsafety.org/current-safety-initiatives/corporate-flight-operational-quality-assurance-c-foqa. ICAO Flight Safety Information Exchange http://www.icao.int/fsix/ The Australian Civil Aviation Safety Authority web site at http://www.casa.gov.au/sms/index.htm including Advisory Circular 172-01(0) September 2005 Guidelines For Preparing A Safety Management System (SMS) at http://www.casa.gov.au/rules/1998casr/172/172c01.pdf, , The Transport Canada Civil Aviation web site at http://www.tc.gc.ca/civilaviation/systemsafety/pubs/menu.htm and The UK Civil Aviation Authority web site at http://www.caa.co.uk/default.aspx?catid=872&pagetype=90&pageid=9953 The Overseas Territories web site at http://www.airsafety.aero/safety_development/sms The IBAC web site at http://www.ibac.org. In addition, chapter 5 Evaluating the Operator’s SMS of the IS-BAO Internal Audit Manual may be helpful in the SMS development process. The NASA web site at http://www.nasa.gov. The FAA Safety Management System information pages at: http://www.faa.gov/about/initiatives/sms/specifics_by_aviation_industry_type/ and Risk Management Handbook at: www.faa.gov/library/manuals/aviation/media/FAA-H-8083-2.pdf The International Helicopter Safety Team (IHST) SMS Toolkit at: http://ihst.rotor.com/Portals/54/2009_SMS_Toolkit_ed2_Final.pdf The European Strategic Safety Initiative (ESSI) at http://www.easa.europa.eu/essi/index.html FAA Advisory Circular 120-92 Introduction to Safety Management Systems for Air Operators at http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/6485143d5ec81aae8625719b0055c9e5/$FILE/AC%20120-92.pdf, and FAA’s Flight Risk Assessment Tool at http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2007/inFO07015.pdf. EASA website www.easa.europa.eu/sms/ Introduction to safety management - 27 june 2012

Introduction to safety management - 27 June 2012 True or false? Annex 19 is called “risk management”. SSP is created by Service Providers ICAO facilitates safety management information sharing among Service Providers within the State EASA oversees Service Providers’ Safety performance Risk management means you can deviate to the rules if properly mitigating factors are in place All statements are false Annex 19 is called «  safety management »; «  risk management »’ is a subset of «  safety management » and is component n’2. SSP means “State Safety Programme” and is therefore applicable to States; SMS (Safety Management System) is applicable to the Service Providers. ICAO does encourage the State for sharing hazard, safety data etc within their territories but the service providers remain under the oversight of the State, not ICAO. ICAO does not rule the Service Providers; the States adopt the Standard and recommended Practices as developed by ICAO by enacting them in their national legislative system and overseeing operations on their territories The service providers located within the EASA-pan world remain under the oversight of the States, not directly under EASA : EASA only oversees the States and their SSP; the States oversees the SMS of their service providers (principle of sovereignty) Risk management is a building block on top of “compliance to the rules”. Remember that the main root cause to incidents and accidents is deviation to the Standard Operating Procedures (SOPs – deviation to the rules or to the organization procedures or to the approved data). Introduction to safety management - 27 June 2012

Any comment or question, contact jean-pierre.arnaud@easa.europa.eu http://intranet/your-intranet-page